Week 3 - Assessment, MSE, Diagnosis/DSM Flashcards
How do Shum, O’gorman & Myers (2006) define a psychological test?
“A psychological test is an objective procedure for sampling and quantifying human behaviour to make inference about a particular psychological construct using standardised stimuli and methods of administration and scoring”
How do McIntire & Miller, (2007)define a psych test?
A psychological test is something that requires you to perform a behavior to measure some personal attribute, trait, or characteristic or to predict an outcome
Types of psychological tests?
LOTS of different types –
IQ tests,
personality tests,
interest and vocational inventories,
tertiary entrance exams,
classroom tests,
structured interviews,
self-report measures,
even self-scored tests you find in Cosmo! (McIntire & Miller, 2007)
Why do we need psych tests?
For decision making
- Classification
- Dx and tx planning
- Program evaluation
-Tests are often better and more accurate than clinical judgment in informing the decision making process
Psychological Tests vs Assessment
Often these terms are used interchangeably, however;
Assessment is more comprehensive
“Assessment can be defined as appraising or estimating the magnitude of one or more attributes of a person. The assessment of human characteristics involves observations, interviews, checklists, inventories, and other psychological tests.”
Tests are only one source of information used in the assessment process
Assessors must combine and compare data from different sources
Eating Disorders Inventory-III
(EDI-III)
Garner (2004)
- 91 items
- one of the most widely used self-report measures of eating disorder related traits
- mostly used for females aged 13 years+
- 3 eating disorder specific scales
- 9 general psych scales
- 6 composite scales
- -Eating Disorder Risk
- -Ineffectiveness
- -Interpersonal Problems
- -Affective Problems
- -Overcontrol
- -General Psychological Maladjustment
EDI-III
Eating Disorder Risk Subscale
Drive For Thinness
Bulimia
Body Dissatisfaction
EDI-III
Ineffectiveness Subscale
Low Self-esteem
Personal Alienation
EDI-III
Interpersonal Problems Subscale
Interpersonal Insecurity
Interpersonal Alienation
EDI-III
Affective Problems Subscale
Interoceptive Deficits
Emotional Dysregulation
EDI-III
Overcontrol Subscale
Perfectionism
Asceticism
EDI-III
General Psychological Maladjustment subscale
Low self esteem Personal alienation Interpersonal insecurity Interpersonal alienation Interoceptive deficits Emotional dysregulation Perfectionism Asceticism Maturity fears
EDI-III
Scoring
uses a 0-4 scoring system
EDI-3 SC (symptom checklist)
Data on Frequency of symptoms
Weight, Weight hx, Menstrual Hx
EDI-3 RF (referral form)
Quick form that can be used to determine whether a referral is necessary (for schools, athletic institutions etc.)
Can you Diagnose with the EDI-III?
NO
however;
gives a lot of rich information pertaining to characteristic associated with eating disorders
Beck Depression Inventory - II
BDI-II
Beck, Steer & Brown (1996)
how many items/scoring
No questionnaire is diagnostic!!!! Just helps…
Scored from 0-3
Scoring – sum of all items: 0-13 - minimal depression 14-19 – mild depression 20-28 – moderate depression 29-63 – severe depression
Good psychometric properties
Beware the ill when using this measure!
Beck Anxiety Inventory
(Beck & Steer, 1990)
purpose/how many items/scoring
Constructed to measure symptoms of anxiety that are minimally shared with depression
21 Items scored from ‘not at all’ (0) to ‘severely’ (3)
Measures severity of anxiety in adults and adolescents
Severity: 0-7: minimal 8-15: mild 16-25: moderate 26-63: severe
Depression Anxiety Stress Scale
(DASS)
how many scales / items
3 scales: Depression, Anxiety & Stress
Each scale contains 14 items,
42 items total
4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week
Scores for Depression, Anxiety and Stress are calculated by summing the scores for the relevant items
Also the DASS21 - 7 items per scale
Good psychometric properties
DASS
Depression Scale
dysphoria hopelessness devaluation of life self-deprecation lack of interest/involvement anhedonia inertia
DASS
Anxiety Scale
autonomic arousal
skeletal muscle effects
situational anxiety
subjective experience of anxious affect
DASS
Stress Scale
levels of chronic non-specific arousal difficulty relaxing nervous arousal being easily upset/agitated irritable/over-reactive and impatient
Achenbach System of Empirically Based Assessment
(ASEBA)
Achenbach, Thomas M. & Rescorla, Leslie A. (2001).
There are parent reports (CBCL),youth reports (YSR) and teacher reports (TRF) for comparison across informants
can either be self-administered or administered through an interview
the first section of this questionnaire consists of 20 competence items
the second section consists of 120 items on behavior or emotional problems during the past 6 months
Two versions : one for children ages 1 1/2 - 5 and another for ages 6 - 18.
Different report forms / norms for males and females
Good psychometric properties
ASEBA Child Behaviour Checklist (CBCL) (for parents)
how many items, scoring
The CBCL/6-18 has 118 items that describe specific behavioral and emotional problems, plus two open-ended items for reporting additional problems.
Parents rate their child for how true each item is now or within the past 6 months using the following scale:
0 = not true (as far as you know)
1 = somewhat or sometimes true
2 = very true or often true.
The CBCL/6-18 scoring profile provides raw scores, T scores, and percentiles for three competence scales (Activities, Social, and School), Total Competence, eight cross-informant syndromes, and Internalizing, Externalizing, and Total Problems.
ASEBA
The six DSM-Oriented scales are?
Affective Problems
Anxiety Problems
Somatic Problems
Attention Deficit/Hyperactivity Problems
Oppositional Defiant Problems
Conduct Problems
The Spence Child Anxiety Scale
(SCAS)
(purpose, what does it assess)
Developed to assess DSM-IV anxiety disorders
Child and parent versions; also a pre-school version
Assesses six domains of anxiety:
- generalized anxiety
- panic/agoraphobia
- social phobia
- separation anxiety
- obsessive compulsive disorder
- physical injury fears
SCAS
items/scoring
Child version: 44 items – 38 address symptoms, 6 reflect response bias
Parent version: 38 items
Preschool version: 28 items
Pre-school teacher: 22 items
Takes around 10 minutes to complete
Rate on a 4-point scale :never (0), sometimes (1), often (2), and always (3), the frequency with which they experience each symptom
Good psychometric properties
Mental Status Examination
(MSE)
What is it?
A template that assists a Clinical Psychologist in the collation and subsequent conceptual organization of clinical information about a client’s emotional and cognitive functioning
By systematically basing observations on verbal and non-verbal behavior, the aim is to increase the reliability of the data upon which subsequent diagnoses and case formulation are made
Following Daniel & Crider (2003) an MSE collates information about the client’s
(i) physical
(ii) emotional
(iii) cognitive state
MSE
physical measures
Appearance
Behaviour
Motor Activity
MSE
Emotional Measures
Attitude
Mood and Affect
MSE
Cognitive Measures
Orientation Attention and Concentration Memory Speech and Language Thought (Form and Content) Insight and Judgement Intelligence and Abstraction
MSE
helps to? description typicall begins how?
Draw attention to the key features that describe the client and frame the presenting problem within a context of who the client is
Typically the description will begin with a statement about their age, gender, relationship status, referrer and presenting problem (i.e., the reason for presentation at the service on the particular occasion)
E.g., “Gill, a young looking 35-year old, single woman was referred by her medical practitioner who had suggested treatment for obesity that was contributing to hypertension.”
MSE
Physical - Appearance
A concise summary of the client’s physical presentation is given to paint a clear mental portrait
dress, grooming, facial expression, posture, eye contact, as well as any relevant noteworthy aspects of appearance
MSE
Physical - Behaviour
May make reference to:
- level of consciousness extending from alert through, drowsy, a clouding of consciousness, stupor (lack of reaction to environmental stimuli) and delirium (bewildered, confused, restless, and disoriented), to coma (unconsciousness)
- degree of arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in anxious and manic states)
- mannerisms (e.g., tics and compulsions).
MSE
Physical - Motor Activity
Describe both the quality and the types of actions observed:
- -reduction in the level of movement (psychomotor retardation)
- -slowed movement (bradykinesia)
- -decreased movement (hypokinesia)
- -absence of movement (akinesia)
- -increases in the overall level of movement (psychomotor agitation)
- -tremor
MSE
Emotional -Attitude
Identifiers may be open, friendly, cooperative, willing, and responsive on one hand or closed, guarded, hostile, suspicious, passive on the other
Describe attentiveness, responses to questions, expression, posture, eye contact, tone of voice
MSE
Emotional:
Mood & Affect
What is mood vs what is affect
Affect (an external expression of an emotional state) is potentially observable
Mood (internal emotional experience that influences perception of the world and behavioural responses) requires clinician to depend on the client’s introspections
MSE
Emotional:
Mood & Affect
(descriptors, stability, range, appropriateness)
Descriptors:
- euthymic (normal non-depressed, reasonably positive mood),
- euphoric,
- dysphoric,
- hostile,
- apprehensive,
- fearful,
- anxious,
- suspicious
Stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability
Range, intensity, and variability of affect can be variously portrayed:
- -restricted (i.e., low intensity or range of emotional expression)
- -blunted (i.e., severe declines in range and intensity of emotional range and expression)
- -flat (i.e., absence of emotional expression,)
- -exaggerated (i.e., an overly strong emotional reaction)
Appropriateness (expression incongruent with verbal descriptions and behavior)
-General responsiveness of the client.
MSE
Cognitive - Orientation
A person’s orientation refers to their awareness of time, place, and person
Orientation for TIME refers to a client’s ability to indicate the current day and date (with acceptance of an error of a couple of days)
Orientation for PLACE can be assessed by why they have presented. Behavior should also be consistent with that expected in the setting in which they have arrived
Orientation for PERSON refers to the ability to know who you are, which can be assessed by asking the client their name and about the names of family members or friends.
MSE
Cognitive - Attention and Concentration
Working memory (Baddeley, 1986; 1990) is the term now used in psychology to refer to the constructs called attention and concentration
The aim is to describe the extent to which a client is able to focus their cognitive processes upon a given target and not be distracted by non-target stimuli
–Digit span (the ability to recall in forward or reverse order increasingly long series of numbers presented at a rate of one per second) is a common way to assess these working memory functions, and normal individuals will recall around 6-8 numbers in a digits forward and 5-6 in digits backwards
“Serial sevens” in which seven is sequentially subtracted from 100. Typically people will make only a couple of errors in 14 trials.
MSE
Cognitive - Memory
A MSE will typically assess memory using the categories of short and long-term memory
Categories do not map neatly onto models of memory in recent cognitive psychology (Andrade, 2001)
Aim of the MSE is to provide a concise description of a person’s behavior and screen them in a manner that can guide further assessment.
Recent or short-term memory
- -ask about a recent topical event or who the President or Prime Minister is
- -listen to three words, repeat them, and then recall them some time later in the interview. Most people will usually report 2-3 words after a 20-minute interval
Visual short-term memory
–copy and then reproduce from memory complex geometrical figures (such as those in the Rey Complex Figure task?)
–Long-term memory can be assessed by asking about childhood events.
MSE
Cognitive - Thought (FORM & Content)
Form (or process) of thought is evident in terms of the
- (i) quantity and speed of thought production
- (ii) the continuity of ideas: (circumstantiality or tangentiality) or may perseverate with the same idea, word, or phrase
They may show a loosening of associations (where the logical connections between thoughts are esoteric (intended for or likely to be understood by only a small number of people with a specialized knowledge or interest)or bizarre)
Flight of ideas (very rapid thinking)
Blocking (person’s speech is suddenly interrupted by silences); circumstantiality (focus of a conversation drifts, but often comes back to the point)
Tangentiality (oblique, digressive, or irrelevant replies to questions)
MSE
Cognitive: Thought (Form & CONTENT)
Content of thought
-Delusions are profound disturbances in thought content in which the client continues to hold to a false belief despite objective contradictory evidence, despite other members of their culture not sharing the same belief
- vary on dimensions of plausibility and systematization
- -persecutory (others are deliberately trying to wrong, harm, or conspire against another)
- -grandiose (an exaggerated sense of one’s own importance, power, or significance)
- -somatic (physical sensations or medical problems)
- -reference (belief that otherwise innocuous events or actions refer specifically to the individual)
- -control, influence and passivity (belief that thoughts, feelings, impulses, and actions are controlled by an external agency or force)
- -nihilistic (belief that self or part of self, others, or the world does not exist)
- -jealous (unreasonable belief that a partner is unfaithful)
- -religious (false belief that the person has a special link with God)
More frequent issues:
- phobias (excessive and irrational fears)
- obsessions (repetitive, and intrusive thoughts, images, or impulses)
- preoccupations (e.g., with illness or symptoms).
MSE
Cognitive - Perception
Hallucinations: perceptual disturbance in which people have an internally generated sensory experience, so that they hear, see (visual), feel (tactile), taste (gustatory), or smell (olfactory) something that is not present or detectible by others
The most frequent hallucinations are auditory and typically involve hearing voices, calling, commanding, commenting, insulting, or criticizing
Hallucinations can also occur when falling asleep (hypnogogic) or when awaking (hypnopompic).
Other perceptual disturbances include:
- -external world is unreal, different, or unfamiliar (derealization)
- -self is different or unreal in that the individual may feel unreal, that the body is distorted or being perceived from a distance (depersonalization)
Perceptions can also be dulled or heightened
MSE
Cognitive: Insight & Judgement
Insight is a dimension that describes the extent to which clients are aware that they have a problem
- -A strong lack of insight can be an important indicator of unwillingness to accept treatment
- -Insight refers also to an awareness of the nature and extent of the problem, the effects of their problem on others, and how it is a departure from normal
Judgment: The ability to make sound decisions can be compromised for a number of reasons
–ascertain if poor decisions are the result of problems in the cognitive processes involved in the decision making process, motivational issues, or failures to execute a planned course of action.
MSE
Cognitive: Speech & Language
Described in terms of:
- Rate (e.g., slow, rapid)
- Intonation (e.g., monotonous)
- Spontaneity
- Articulation
- Volume
- Quantity of information conveyed:
- —–mutism (i.e., absence of speech)
- —–poverty of speech (i.e., reduced spontaneous speech)
- —-pressured speech (i.e., rapid speech that is hard to interrupt and understand)
-Language includes reading, writing, and comprehension.
- Disturbances such as aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write)
- –Non-fluent (where speech is slow, faltering, or effortful) or fluent
- –Fluent aphasia speech that is normal in terms of its form (rhythm, quantity, and intonation), but is a meaningless perhaps including novel words (i.e., neologisms).
MSE
Cognitive: Intelligence & Abstraction
A general indication of intelligence is said to be gained from the amount of schooling a person has had (?!):
- -failure to complete high school indicating below average
- –completion of high school indicating average intelligence
- —-college or university education indicating high intelligence
Abstraction is the ability to recognize and comprehend abstract relationships – to extract common characteristics from a group of objects (e.g., in what way are an apple/banana or music/sculpture alike?), interpretation (e.g., explaining a proverb such as a stitch in time saves nine).
Versions of the MSE
MMSE, CCSE, HSCS, MSQ, SPMSQ
Mini Mental State Exam (Folstein, et al., 1975)
- -11-items, measure orientation, registration, attention & calculation, recall, language, and praxis
- -Scores ranges from 0-30 and lower scores indicate greater impairment
- -less sensitive for cases with milder impairment
- -scores influenced by educational level
Cognitive Capacity Screening Examination (CCSE; Jacobs, et al., 1977)
–30-item screener to detect diffuse organic disorders; more appropriate for cognitively intact individuals
High Sensitivity Cognitive Screen (HSCS; Faust & Fogel, 1989)
–15-item scale; valid and reliable indicator of cognitive impairment
Mental Status Questionnaire (MSQ; Kahn, et al., 1960)
–10-item scale that shares the same weaknesses as MMSE but omits some key domains of function (e.g., retention and registration)
Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975)
–10-item scale for community or institutional residents; reliable indicator of organicity.
Formal MSE - note
Formal MSE – not necessarily appropriate for all clients in all settings
Depends on level of psychopathology
Depends on requirements of setting
DIAGNOSIS
Purposes of Diagnosis
Communication – lets us talk about a particular group of issues
Research – we’ve talked about the good and bad of this before – we can look at ‘when we have an individual with these particular problems…we know x, y, and z about them – because it has been shown to be so’
It makes research easier
(NOT categorising people – we are classifying disorders that people have!)
Treatment – helps to guide treatment
If we know that this person has Depression – then we have some idea of what best practice is for that disorder and where to go with it
DIAGNOSIS
issues with diagnosis
Stigma, labelling:
- -Heterogeneity
- -Public perceptions
- -Important implications
- -Self-fulfilling prophecy
Categorical approach
- -Heterogeneity
- -Dimensional?
DIAGNOSIS
issues with diagnosis - stigma & labelling
People assume that all people with a particular ‘label’ are the same – but very heterogeneous – even within the category – have to have 7 of the 9 etc
Worst with the public – e.g., ‘schizpophrenic’ – thanks to movies and ACA – people seem to think that they’re all knife-wielding maniacs reading to kill you as look at you – completely untrue – a very SMALL subsample of that population
Another point – try not to used ‘shizophrenic’ – a person with schizphrenia – the person has a disorder, they are NOT their label
Once a label is given, it’s hard to get rid of
Self-fulfilling prophecy – I’m this, and therefore I’ll always be this, and really then they always will – behave in accordance with their label or use it as an excuse – can get in the way of treatment
DSM 5
description of it
First major revision in 20 years
Has taken 6 years
Have tried to make it tie in better with ICD-10 (and the future ICD-11)
Trying to help psychiatry (and presumably psychology) ‘better resemble medicine’…
Emphasise development, gender and culture on the presentation of disorders
DSM 5 (introduced when? changes?)
Introduced 2013
–947 pages; ? Diagnoses
Change in number system which allows for ‘point upgrades’ (cynically, for more sales as it cost APA US$25 million to produce)
Many changes in diagnoses and their criteria & organisation of diagnoses
Removal of multi-axial system (explained later)
DSM 5
Chapters/Clusters
Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical Attention
DSM - 5
Definition of a Mental Disorder
A mental disorder is a syndrome characterized by Clinically Significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are Usually Associated with significant distress or disability in social, occupational, or other important activities. An Expectable or Culturally Approved response to a common stressor or loss, such as the death of a loved one, is NOT a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders Unless the deviance or conflict results from a dysfunction in the individual, as described above.’
DSM
things to note
Medical model
Descriptive
Guidelines - not cookbook
Clinical judgement = important
Does not require knowledge of its aetiology
Need to be mindful of cultural issues
Need more than diagnosis to develop treatment plan
DSM
Coding and Reporting
Codes – subtypes – specifiers
Subtypes are mutually exclusive
Specifiers are not mutually exclusive (e.g., PTSD - chronic with delayed onset)
—Under DSM-5 some disorders and subtypes share the same code (e.g., 309.81 = PTSD) to make sure it is consistent with ICD-10 (upon which the US and Aus government and insurance companies rely for billing and funding, of course)
DSM
Subtypes, Specifiers & Severity
Subtype: “Specify whether”—only choose one;
Specifier: “Specify if”—pick as many as apply;
Severity: “Specify current severity”—choose the most accurate level of symptomology.
DSM
Ordering Diagnoses
The first diagnosis is called the principal diagnosis. In an inpatient setting, this would be the most salient factor that resulted in the admission (APA, 2013). In an outpatient environment, this would be the reason for the visit or the main focus of treatment. The secondary and tertiary diagnoses should be listed in order of need for clinical attention.
DSM-5
Diagnosis
(provisional / not otherwise specified)
Provisional diagnosis: think criteria will be met but as yet not enough information
Not otherwise specified:
Four situations:
–Conforms to diagnostic class but does not meet criteria of subtypes (atypical/mixed presentation)
–Conforms to symptom pattern not in DSM (clinically significant distress/impairment)
–Uncertainty about aetiology (medical?)
–Insufficient information available (emergency/contradictory information)
DSM-5
Multi-Axial Diagnosis
Discontinued 5-Axis system
No more problems of “Axis 2” or GAF?
NOS replaced by “Other Specified” or “Unspecified”
“Another Medical Condition” instead of “General Medical Condition”
Axis 4 gone
- -might use V (or Z in ICD 10) codes:
- —These are designed for occasions when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems or factors that influence care. These codes represent the reason why the psych – patient encounter exists. It may be more for financial coding reasons used by insurance companies and health departments, not a measure of psychosocial / environmental stressors!
Axis 5 gone
- -might use WHODAS. (World Health Org Disability Assessment Schedule)
- -List multiple diagnoses in order of attention or concern
Process of Differntial Diagnosis
How to differentiate one disorder from others with similar presenting characteristics
A process of systematically considering & ruling out other possibilities
Appendix A – decision trees for differential diagnosis
Read Differential Diagnosis section for disorder – consider all possibilities
Especially consider – substance-related disorders, medical conditions, adjustment disorder, clinical significance, rule out factitious disorder/malingering
